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BACKGROUND
DAPT with ASA and a P2Y12 inhibitor has become a mainstay of therapy in ACS. Although
ticagrelor was demonstrated to be superior to clopidogrel in the PLATO trial, North
American patients did not demonstrate mortality benefit. A recent observational study
of 13,897 patients from Alberta who had undergone PCI for ACS revealed that there
was no difference in mortality or incidence of MACE between patients prescribed ticagrelor
compared to clopidogrel when adjusted for age and comorbidities, but there was an
increase in major bleeding in patients receiving ticagrelor. It is important to evaluate
the efficacy of these P2Y12 inhibitors in the real-world setting.
METHODS AND RESULTS
We conducted a retrospective cohort study of all patients who were diagnosed with
ACS and underwent PCI in a single Canadian province from January 1, 2015 to December
31, 2017. Baseline characteristics including comorbidities, medications, and bleeding
risk were obtained. Propensity matching and stabilized inverse probability treatment
weighting (IPTW) were used to compare patients who received ticagrelor as opposed
to clopidogrel. The primary outcome was occurrence of MACE at 12 months, defined as
death, nonfatal MI, or unplanned revascularization. Secondary outcomes included all-cause
mortality, major bleeding, stroke, and any-cause hospitalization. A total of 3575
patients who underwent PCI for ACS were included. 1380 received clopidogrel and 2195
received ticagrelor. Patients who received clopidogrel were older and significantly
more likely to have comorbidities including hypertension, COPD, peripheral vascular
disease, CKD, previous ACS, previous bleeding, and HAS-BLED score 2. In 1229 propensity-score-matched
pairs, there were no differences between patients given ticagrelor compared to clopidogrel
in MACE (HR 0.91; 0.74-1.12 p=0.39), all-cause mortality (HR 1.00; 0.62-1.62, p=1.00),
major bleeding (HR 0.85;0.44-1.64 p=0.62), or stroke (HR 0.50; 0.15-1.66, p=0.256).
There was a statistically significant reduction in hospitalizations among patients
treated with ticagrelor (HR 0.86; 0.71-0.99, p < 0.01). The stabilized IPTW analysis
showed comparable results.
CONCLUSION
In a contemporary real-world cohort of ACS patients managed with PCI, ticagrelor use
is associated with reduced hospitalization, but no MACE or mortality benefit in 12
months from their index PCI. These results suggest that a personalized approach to
DAPT, taking into account comorbidities, ischemic, and bleeding risk may be preferable
to routine use of ticagrelor in ACS patients. Analyzing data from a larger ACS patient
cohort treated with PCI may help identify patient subgroups that may benefit most
from use of ticagrelor as the P2Y12 inhibitor of choice.
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© 2021 Published by Elsevier Inc.